Empyema
Empyema
Empyema
070100415
Stages
Acute (exudative) stage:
Approximately in 3-7 days
Pleura fills with thin serous fluid that shows one or more of these criteria;
- Ph < 7.4 - Glucose <40 mg/dl - LDH> 1000 iu/dl - Protein > 2.5 gm/dl
Stages
Transitional (Fibrinopurulent) stage:
From day 7 to 21 day
Thick,opaque fluid with positive culture (pus) and deposition of thin fibrin layer over the pleura. Progressive loculation and formation of pouches in the pleura.
Stages
Chronic (organizing) stage:
after 21 days
Presence of very thick pus Thick inelastic peel over both pleura causing entrapment of the lung (abscess formation)
Clinical stages
Acute stage : within the first 2 weeks of the onset.
Chronic Stage : after 2 weeks or with the formation of the thick peel and loculations.
Causes of chronicity
Inadequate tube drainage. Chronic pulmonary disease ( T.B. or fungal Infection) Immunosupressed patients.
Complications
Rupture into the lung: Bronchopleural fistula Spread to the subcutaneous tissue: Empyema Niscitanes Septicaemia & septic shock.
Diagnosis
On a chest X-ray, empyema will appear as a cloudy or opaque area In physical examination:
Contralateral tracheal shift possible with large effusions Decreased tactile fremitus Dullness to percussion Decreased or absent breath sounds
The diagnosis of empyema has to be confirmed with laboratory tests based on fluid analysis because its symptoms can be caused by other disease conditions. Aerobic pus usually gives off a little odor
Investigations
Chest X-ray C-T scan Ultrasonography Thoracentesis
Chest X ray
The white patch in both x-ray photographs is due to the presence of pus.
CT scan
USG
Ultrasound image of a large parapneumonic effusion demonstrates thick septations (white arrows) within the fluid in keeping with an exudate
Thoracentesis
This is a procedure which involves the insertion of a needle into the pleural cavity through the back between the ribs on the infected side, and a sample of fluid is withdrawn It is performed under local anesthetics If the patient has empyema, there will be leukocytosis, a high level of protein, and a very low level of blood sugar
Thoracentesis
This is the most useful test that conducts analysis of aspirated pleural fluid which shows: transudative effusions: lactate dehydrogenase (LDH) levels less than 200 IU and protein levels less than 3 g/dl exudative effusions: ratio of protein in pleural fluid to serum greater than or equal to 0.5, LDH in pleural fluid greater than or equal to 200 IU, and ratio of LDH in pleural fluid to LDH in serum greater than or equal to 0.6 empyema: acute inflammatory white blood cells and microorganisms empyema or rheumatoid arthritis: extremely decreased pleural fluid glucose levels
Management
Control of the Infection process Drainage of pus form the pleura Obliteration of the space & complete Reexpansion of the Lung
Management
Early-course: aspiration, Ab, and sometimes fibrinolytic therapy
Management
Empyema is treated using a combination of medications and surgical Treatment with medication involves intravenously administering a two-week course of antibiotics It is important to give antibiotics as soon as possible to prevent first-stage empyema from processing to its later stage The antibiotics most commonly used are penicillin and vancomycin.
Management
In 1st stage empyema, give Ab and fibrinolytic therapy, drainage if effusion is significant In 2nd stage empyema, insertion a chest tube in the patients rib cage or remove part of a rib (rib resection) In 3rd stage empyema, cuting or peel away the thick fibrous layer coating the lung, a procedure which is called decortication
Ab therapy
Dependent on identification of causative organism Appropriate therapy requires isolation of organism from blood, pleural fluid or sputum Empiric therapy should be based on local epidemiology and should cover S. pneumonia, S. pyogenes and S. aureus Broad spectrum therapy with Ceftriaxone/Cefotaxime plus Clindomycin
Fibrionlytic therapy
Studies used Streptokinase or Urokinase Most effective in the early fibrinopurulent stage and may make surgical drainage unnecessary Indications:
- Acute or fibrinopurulent stage - Presence of loculations - Incomplete drainage after tube insertion
Contraindications:
- Chronic stage - Post-operative empyema - Empyema with broncopleural fistual
Troracotomy
Open drainage with pleural peel decortication Excision of the thick fibrous pleural and removal of infectious material Longer & complicated procedure Reserved for late presenting empyema with significant fibrous pleural, complex empyema & chronic empyema